RX Summ--Chemo [1390]

Field Length:  2

The data item Chemotherapy records the chemotherapy given as a part of the first course of treatment or the reason that chemotherapy was not given.

See SEER*Rx for chemotherapy drug codes and for information on the drug’s function.

Important update effective for diagnosis date January 1, 2013 forward

A comprehensive review of chemotherapeutic drugs currently found in the SEER*Rx – Interactive Drug Database was performed and in keeping with the U.S. Food and Drug Administration (FDA), the six (6) drugs listed in the table below have changed categories from Chemotherapy to BRM/Immunotherapy.

This change is effective for cases diagnosed January 1, 2013 forward. For cases diagnosed prior to January 1, 2013, code these six (6) drugs as chemotherapy. Coding instructions related to this change have been added to the Remarks section for the applicable drugs in SEER*Rx.

Note: Use the date of diagnosis, not the date of treatment, to determine whether to code these drugs as chemotherapy or BRM/Immunotherapy.

Example 1: Patient diagnosed with HER2 positive breast cancer December 15, 2023, and was placed on planned Herceptin February 2, 2024. Code Herceptin in the BRM/Immunotherapy data item (as the patient was diagnosed after January 1, 2013).

Example 2: Patient diagnosed with breast cancer November 1, 2012, and begins receiving Rituximab January 30, 2013, as part of first course therapy. Code the Rituximab in the Chemotherapy data item because the patient was diagnosed prior to January 1, 2013.

Definitions

Chemotherapy recommended: A consult recommended chemotherapy, or the attending physician documented that chemotherapy was recommended. A referral to a clinical oncologist is equivalent to a recommendation.

Multiple agent chemotherapy: Planned first course of therapy included two or more chemotherapeutic agents and those agents were administered. The planned first course of therapy may or may not have included other agents such as hormone therapy, immunotherapy, or other treatment in addition to the chemotherapeutic agents.

Single agent chemotherapy: Only one chemotherapeutic agent was administered to destroy cancer tissue during the first course of therapy. The chemotherapeutic agent may or may not have been administered with other drugs classified as immunotherapy, hormone therapy, ancillary, or other treatment.

Coding Instructions

1. Code the chemotherapeutic agents whose actions are chemotherapeutic only; do not code the method of administration

2. When chemotherapeutic agents are used as radiosensitizers or radioprotectants, they are given at a much lower dosage and do not affect the cancer. Radiosensitizers and radioprotectants are classified as ancillary drugs. See SEER*Rx. Do not code as chemotherapy. Review the radiation-oncology progress notes for information about radiosensitizing chemotherapy.

Note: Do not assume that a chemo agent given with radiation therapy is a radiosensitizer. Seek additional information. Compare the dose given to the dose normally given for treatment.

For additional information, see

• • • The National Cancer Institute Physician Data Query (PDQ), Health Professional Version

AND/OR

• • • The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology

3. The physician may change a drug during the first course of therapy because the patient cannot tolerate the original agent

a. This is a continuation of the first course of therapy when the chemotherapeutic agent that is substituted belongs to the same group (alkylating, antimetabolites, natural products, targeted therapy, or other miscellaneous)

b. Do not code the new agent as first course therapy when the original chemotherapeutic agent is changed to one that is NOT in the same group. Code only the original agent as first course. When the new agent is in a different group, it is second course therapy.

c. Use SEER*Rx and compare the subcategory of each chemotherapy agent to determine whether or not they belong to the same group (subcategory). See “Chemotherapeutic Agents” below for the groups and their definitions.

4. Code as treatment for both primaries when the patient receives chemotherapy for invasive carcinoma in one breast and also has an invasive or in situ carcinoma in the other breast. Chemotherapy would likely affect both primaries.

Example: Patient is diagnosed with infiltrating duct carcinoma, stage III, in the right breast and infiltrating duct carcinoma, stage I, in the left breast. Neoadjuvant chemotherapy is administered for the stage III neoplasm in the right breast per the breast surgeon consult, but not for the left breast. Code the chemotherapy on both abstracts for both primaries in this case (simultaneous bilateral breast primaries).

5. Assign code 00 when

a. The medical record documents chemotherapy was not given, was not recommended, or was not indicated

b. There is no information in the patient’s medical record about chemotherapy, AND

i. It is known that chemotherapy is not usually performed for this type and/or stage of cancer

OR

ii. There is no reason to suspect that the patient would have had chemotherapy

c. The treatment plan offered multiple treatment options and the patient selected treatment that did not include chemotherapy

d. Patient elects to pursue no treatment following the discussion of chemotherapy. Discussion does not equal a recommendation. Patient's decision not to pursue chemotherapy is not a refusal of chemotherapy in this situation.

e. Active surveillance/watchful waiting is the first course of treatment (e.g., CLL)

f. Patient diagnosed at autopsy

Example: Patient is diagnosed with plasma cell myeloma. There is no mention of treatment or treatment plans in the medical record. Follow-back finds that the patient died three months after diagnosis. There are no additional medical records or other pertinent information available. Assign code 00 since there is no reason to suspect that the patient had been treated.

6. Do not code combination of ancillary drugs administered with single agent chemotherapeutic agents as multiple chemotherapy. For example, the administration of 5-FU (antimetabolite) and Leucovorin (ancillary drug) is coded to single agent (Code 02).

7. Assign code 82 when chemotherapy is a customary option for the primary site/histology but it was not administered due to patient risk factors, such as

a. Advanced age

b. Comorbid condition(s) (heart disease, kidney failure, other cancer, etc.)

c. Progression of tumor prior to administration

8. Assign code 87 when

a. The patient refused recommended chemotherapy

b. The patient made a blanket refusal of all recommended treatment and chemotherapy is a customary option for the primary site/histology

c. The patient refused all treatment before any was recommended and chemotherapy is a customary option for the primary site/histology

9. Assign code 88 when the only information available is

a. The patient was referred to an oncologist

b. Insertion of port-a-cath

Note: Review cases coded 88 periodically for later confirmation of chemotherapy.

10. Assign code 99 when there is no documentation that chemotherapy was recommended or administered

a. For death certificate only (DCO) cases

Chemotherapeutic Agents

Chemotherapeutic agents are chemicals that affect cancer tissue by means other than hormonal manipulation. Chemotherapeutic agents can be divided into five groups.

• Alkylating agents
• Antimetabolites
• Natural products
• Targeted therapy
• Miscellaneous

Alkylating Agents

Alkylating agents are not cell-cycle-specific. Although they are toxic to all cells, they are most active in the resting phase of the cell. Alkylating agents directly damage DNA to prevent the cancer cell from reproducing.

Alkylating agents are used to treat many different cancers including acute and chronic leukemia, lymphoma, Hodgkin disease, multiple myeloma, sarcoma, and cancers of the lung, breast, and ovary. Because the drugs

damage DNA they can cause long-term damage to the bone marrow and can, in rare cases, lead to acute leukemia. The risk of leukemia from alkylating agents is “dose-dependent.” Examples of alkylating agents include

• Mustard gas derivatives/nitrogen mustards: mechlorethamine, cyclophosphamide, chlorambucil, melphalan, and ifosfamide
• Ethylenimines: thiotepa and hexamethylmelamine
• Alkylsulfonates: busulfan
• Hydrazines and Trizines: altretamine, procarbazine, dacarbazine, and temozolomide
• Nitrosureas: carmustine, lomustine, streptozocin, and nitrosourea are unique because they can cross the blood-brain barrier and can be used in treating brain tumors
• Metal salts: carboplatin, cisplatin, and oxaliplatin

Antimetabolites

Antimetabolites are cell-cycle specific. Antimetabolites are very similar to normal substances within the cell. When the cells incorporate these substances into the cellular metabolism, they are unable to divide.

Antimetabolites are classified according to the substances with which they interfere.

• Folic acid antagonist: methotrexate
• Pyrimidine antagonist: 5-fluorouracil, floxuridine, cytarabine, capecitabine, and gemcitabine
• Purine antagonist: 6-mercaptopurine and 6-thioguanine
• Adenosine deaminase inhibitor: ladribine, fludarabine, nelarabine, and pentostatin

Natural Products

1. Plant Alkaloids are cell-cycle specific which means they attack the cells during various phases of division. They block cell division by preventing microtubule function. Microtubules are vital for cell division.

Without them, division cannot occur. Plant alkaloids, as the name implies, are derived from certain types of plants.

• • • Vinca alkaloids: vincristine, vinblastine, and vinorelbine
    • Taxanes: paclitaxel and docetaxel
    • Podophyllotoxins: etoposide and teniposide
    • Camptothecan analogs: irinotecan and topotecan

2. Antitumor antibiotics are also cell-cycle specific and act during multiple phases of the cell cycle. They are made from natural products and were first produced by the soil fungus Streptomyces. Antitumor antibiotics form free radicals that

break DNA strands, stopping the multiplication of cancer cells.

• • • Anthracyclines: doxorubicin, daunorubicin, epirubicin, mitotane, and idarubicin
    • Chromomycins: dactinomycin and plicamycin
    • Miscellaneous: mitomycin and bleomycin

3. Topoisomerase inhibitors interfere with the action of topoisomerase enzymes (topoisomerase I and II). They control the manipulation of the structure of DNA necessary for replication.

• • • Topoisomerase I inhibitors: irinotecan, topotecan
    • Topoisomerase II inhibitors: amsacrine, etoposide, etoposide phosphate, teniposide

Targeted Therapy

Targeted cancer therapies are drugs or other substances that block the growth and spread of cancer by interfering with specific molecules ("molecular targets") that are involved in the growth, progression, and spread of cancer.

Targeted cancer therapies are sometimes called "molecularly targeted drugs," "molecularly targeted therapies," "precision medicines," or similar names. Examples of molecularly targeted therapy are imatinib (Gleevec), lapatinib (Tykerb), erlotinib (Tarceva), sunitinib (Sutent).

Miscellaneous

Miscellaneous antineoplastics that are unique

• Ribonucleotide reductase inhibitor: hydroxyurea
• Adrenocortical steroid inhibitor: mitotane
• Enzymes: asparaginase and pegaspargase
• Antimicrotubule agent: estramustine
• Retinoids: bexarotene, isotretinoin, tretinoin (ATRA)

Coding for Tumor Embolization

The American College of Surgeons Commission on Cancer (CoC), the Centers for Disease Control and Prevention National Program of Cancer Registries (NPCR), and the SEER Program have collaborated to clarify and refine coding directives for tumor embolization and are jointly issuing the following instructions.

Definitions

Chemoembolization: A procedure in which the blood supply to the tumor is blocked surgically or mechanically and anticancer drugs are administered directly into the tumor. This permits a higher concentration of drug to be in contact with the tumor for a longer period of time.

Radioembolization: Tumor embolization combined with the injection of small radioactive beads or coils into an organ or tumor.

Tumor embolization: The intentional blockage of an artery or vein to stop the flow of blood through the desired vessel.

Coding Instructions

Code as Chemotherapy when the embolizing agent(s) is a chemotherapeutic drug(s). Use SEER*Rx to determine whether the drugs used are classified as chemotherapeutic agents. Use codes 01, 02, 03 as specific information regarding the agent(s) is documented.

Example: The patient has hepatocellular carcinoma (primary liver cancer). From a procedure report: Under x-ray guidance, a small catheter is inserted into an artery in the groin. The catheter’s tip is threaded into the artery in the liver that supplies blood flow to the tumor. Chemotherapy is injected through the catheter into the tumor and mixed with particles that embolize or block the flow of blood to the tumor.

Do not code pre-surgical (pre-operative) embolization of hypervascular tumors with agents such as particles, coils, or alcohol as a treatment. Pre-surgical embolization is typically performed to prevent excess bleeding during the resection of the primary tumor. Examples where pre-surgical embolization is used include meningiomas, hemangioblastomas, paragangliomas, and renal cell metastases in the brain.